Αγγειοπλαστική των πνευμονικών αρτηριών στην χρόνια θρομβοεμβολική πνευμονική υπέρταση. Παρόν και μέλλον

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1 Αγγειοπλαστική των πνευμονικών αρτηριών στην χρόνια θρομβοεμβολική πνευμονική υπέρταση. Παρόν και μέλλον Παναγιώτης Καρυοφύλλης Επιμελητής Β Ωνάσειο Καρδιοχ/κό Κέντρο

2 CTEPH is an obstructive disease

3 Pulmonary endarterectomy (PEA) is the treatment of choice for CTEPH Diagnosis confirmed by CTEPH expert centre Lifelong anticoagulation Operability assessment by a multidisciplinary CTEPH team Technically operable Technically non-operable Acceptable risk:benefit ratio Non-acceptable risk:benefit ratio a Targeted medical therapy PEA Persistent symptomatic PH Consider BPA in expert centre b Consider lung transplantation Persistent severe symptomatic PH a Technically operable patients with non-acceptable risk/benefit ratio can also be considered for BPA. b Galiè N, et al. Eur Respir J 2015; 46:903-75; In some centres medical therapy and BPA are initiated concurrently. Galiè N, et al. Eur Heart J 2016; 37: BPA: balloon pulmonary angioplasty, PEA: pulmonary endarterectomy.

4 Recommendations for PEA: ESC/ERS guidelines Recommendations Class a Level b In PE survivors with exercise dyspnoea, CTEPH should be considered IIa C Life-long anticoagulation is recommended in all patients with CTEPH I C It is recommended that in all patients with CTEPH the assessment of operability and decisions regarding other treatment strategies should be made by a multidisciplinary team of experts Surgical PEA in deep hypothermia circulatory arrest is recommended for patients with CTEPH Riociguat is recommended in symptomatic patients who have been classified as having persistent/recurrent CTEPH after surgical treatment or inoperable CTEPH by a CTEPH team including at least one experienced PEA surgeon Off-label use of drugs approved for PAH may be considered in symptomatic patients who have been classified as having inoperable CTEPH by a CTEPH team including at least one experienced PEA surgeon Interventional BPA may be considered in patients who are technically non-operable or carry an unfavourable risk:benefit ratio for PEA I I I IIb IIb C C B B C Screening for CTEPH in asymptomatic survivors of PE is currently not recommended III C a Class of recommendation. b Level of evidence. Galiè N, et al. Eur Respir J 2015; 46:903-75; Galiè N, et al. Eur Heart J 2016; 37:

5 Cumulative Survival PEA significantly improves the long-term prognosis of CTEPH patients compared with non-operated patients Operated, n = NOT-operated, n = p < (log-rank test) Time from diagnosis (months) Patients at risk at the end of the time period Delcroix M, et al. Circulation 2016; 133:

6 Rationale for PEA Complete removal and clearance of PA obstructions Reduces pulmonary arterial pressure Improve pulmonary perfusion, oxygenation, RV function and dead space ventilation Improve life expectancy and quality of life Fedullo PF, et al. N Engl J Med 2001; 345: ; Mayer E, et al. Eur respir Rev 2010; 19:64-76; Simonneau G, et al. Am J Respir Crit Care Med 2013; 187:A5365.

7 36% inoperable, 43% not operated

8

9 Interventional BPA may be considered in patients who are technically non-operable or carry an unfavourable risk to benefit ratio for PEA Diagnosis confirmed by CTEPH expert centre Lifelong anticoagulation IC Operability assessment by a multidisciplinary CTEPH team Technically operable Technically non-operable Acceptable risk:benefit ratio Non-acceptable risk:benefit ratio a Targeted medical therapy IB IC PEA Persistent symptomatic PH Consider BPA in expert centre b Consider lung transplantatio n Persistent severe symptomatic PH IIbC a Technically operable patients with non-acceptable risk/benefit ratio can also be considered for BPA. b In some centres medical therapy and BPA are initiated concurrently. BPA: balloon pulmonary angioplasty, PEA: pulmonary endarterectomy Galiè N, et al. Eur Respir J 2015; 46:903-75; Galiè N, et al. Eur Heart J 2016; 37:

10 What is Balloon Pulmonary Angioplasty (BPA)? BPA is an interventional treatment that uses a balloon catheter to dilate pulmonary stenosis or obstruction. BPA was first developed in the field of pediatric cardiology for treating congenital stenotic pulmonary arteries. The development of BPA for the treatment of inoperable CTEPH patients is extremely slow The first attempt to treat inoperable CTEPH case by BPA was performed in ((Voorburg JA, et al. Chest 1988;94: )

11 First case series: 13 years later Averaged 2.6 procedures, 6 dilations mpap decreased from 43.0 to 33.7 mmhg About 60 % of patients developed reperfusion edema (one patient died)

12 12 years later the 1 st European publication Averaged 3.7±2.1 procedures, 20 patients mpap decreased from 45±11 to 33±10 mmhg About 45 % of patients developed reperfusion edema (two patients died) Heart 2013;99:

13 TPR (mmhg/l/min/m ) 2 Relation between pulmonary vascular obstruction and pulmonary resistance in APE y =1578/( x) Only minor improvement in pulmonary vascular obstruction could significantly decrease PAP Pulmonary Vascular Obstruction (%) Azarian R, et al. J Nucl Med 1997; 38:

14 BPA may exert multiple beneficial effects in CTEPH patients Parameter Before BPA (n = 35) After BPA (n = 35) p value Functional class I/II, III/IV 0/22, 12/1 7/28, 0/0 < MWD (min) 408 ± ± 146 < 0.01 BNP(pg/ml) 252 ± ± 23 < Oxygen therapy 27 (77) 20 (57) < 0.05 Haemodynamics mpap (mmhg) 35 ± 9 24 ± 6 < Heart rate (beat/min) 69 ± 9 61 ± 9 < PVR (dyne s cm 5 ) 482 ± ± 80 < Renal function Cr (mg/dl) 0.82 ± ± 0.25 < egfr (ml/min/1.73 m 2 ) 65.5 ± ± 19.5 < Glycaemic control Fasting blood glucose (mg/dl) 98 ± ± 11 < 0.05 HbA1c (%) 5.8 ± ± 0.4 < 0.01 Results are expressed as a number (%) or mean ± SD. Tatebe S, et al. Circ J 2016; 80:980-8.

15 - 63%

16 BPA in CTEPH: Results on PVR

17 The most representative results with BPA in the management of patients with inoperable CTEPH First Author (year) Fenstein (2001) Andreassen (2013) Kurzyna (2017) Pts Procedures Baseline mpap (mmhg) mpap post BPA (mmhg) Mean change (%) Baseline PVR (WU) PVR post BPA Mean change (%) n of deaths Mortality/proce dures (%) ±12 33±10-21 *22±9 *17±8-23 1/ ±11 33± ± ± / ± ±9.3-30** 10.3± ±2.8-43** 3/1.9 Velázquez ± ± ±4 5.5±2-47 1/1.3 (2016) Olsson ±12 33± ± ± /0.4 (2017) Mizoguchi ±9.6 24± ± ± /0.4 (2012) Kimura ± ± ± ± /0 (2016) Inami /0.3 (2016) Ogo ±11 25± ± ± /0 (2016) Kawakami ± ± ± ± /0.8 (2016) Aoki ± ± ± ± /0 (2017) Ogawa ± ± ± ± /0.6 * Values for Total Pulmonary Resistance (TPR) expressed in WU m 2 ** Results from 31 patients who completed their BPA treatment or underwent at least 3 sessions

18 Forest plot for haemodynamic outcomes of observational studies on medical therapy and BPA for CTEPH (A) mpap, (B) PVR.

19 Balloon Pulmonary Angioplasty (BPA)-Indications Unsuitable cases for PEA (surgically inaccessible lesions, surgically accessible but inoperable because of comorbidities, and cases of residual or recurrent pulmonary hypertension after PEA) Ogawa A, Matsubara H. Frontiers in Cardiovascular Medicine. 2015, doi: /fcvm

20 Balloon Pulmonary Angioplasty (BPA)-Contraindications Contraindications of BPA include iodine allergy, as the use of a contrast medium is essential in BPA. Additionally, in cases with renal dysfunction, the benefits of performing BPA must be weighed against the risks. Severity of pulmonary hypertension may not necessarily be a contraindication of BPA. Although previous reports have indicated a higher mean PAP at baseline is associated with more frequent complications, the patient prognosis will be worse without effective treatment in cases with severe hemodynamics. BPA can be expected to have more powerful effect in these patients Ogawa A, Matsubara H. Frontiers in Cardiovascular Medicine. 2015, doi: /fcvm

21 Balloon Pulmonary Angioplasty (BPA) Selective PAG Balloon dilatation Post BPA

22 A demanding technique in complex anatomy. Anatomy of pulmonary artery Both PAs (AP) Right PA (LAO 60) Left PA (LAO 60)

23 Selection of segmental arteries Generally, almost all segmental arteries can be easily selected by using Judkins right type guiding catheter. Usage of multi purpose type guiding catheter for right PA and Amplatz left (AL1) type guiding catheter for left PA are recommended. Usage of AL 1 type guiding catheter would be necessary in selecting rt A5 and A7.

24 Suitable guiding catheters for each segmental pulmonary artery Right side Guiding Catheter Left side Guiding Catheter A1 MP < JR-4 A2 MP < JR-4 A1+2 MP < JR-4 A3 MP A3 AL-1 < JL-4 A4 MP A4 AL-1 > JL-4 A5 AL-1 > MP A5 AL-1 > JL-4 A6 MP A6 MP > AL-1 A7 AL-1 > JR A8 MP A8 MP < AL-1 A9 MP A9 MP < AL-1 A10 MP A10 MP < AL-1 MP: Multipurpose type, AL: Amplatz left type, JL: Judkins left type, JR: Judkins right type.

25 Recognition of the lesions Clearly recorded PAG with deep breath is essential in finding out lesions. Most frequently observed lesions are web and exist in almost all segments Most of web lesions only appear slightly hazy in PAGs. Following findings will be some help to recognize lesions. lesion distal delayed flow loss of capillary staining in perfused area occurrence of prominent pulsatile movement of lesion proximal artery

26 Representative PAG of CTEPH patient lesion distal delayed flow loss of capillary staining of perfused area occurrence of prominent pulsatile movement of lesion proximal artery

27 5 lesion types are recognized in CTEPH patients

28 Complications of BPA Averaged 2.6 procedures, 6 dilations mpap decreased from 43.0 to 33.7 mmhg About 60 % of patients developed reperfusion edema (one patient died) Averaged 4 procedures, 12 dilations mpap decreased from 45.4 to 24.0 mmhg 60 % of patients developed reperfusion edema (one patient died)

29 Complication; Pulmonary injury Complications Pulmonary injury Pulmonary artery perforation Pulmonary artery rupture Diagnostic Criteria Hemoptysis Chest radiographic opacities Chest computed tomographic opacities

30 Pulmonary injury The most frequent and characteristic complication of BPA is pulmonary injury. Pulmonary vessel injury caused by the guidewire, guiding catheter, balloon dilation, or contrast medium injection at high pressure may play a role in inducing pulmonary injury in BPA. It is necessary to determine how to dilate the lesion to achieve maximal therapeutic efficacy and reduce the risk of pulmonary vessel injury, which could potentially become lethal. To dilate the lesion, balloon size, vessel size, the number of organised thrombi and patient haemodynamics must be considered. Balloon size is the only one of these factors we can control.

31 Angiographic extravasation findings of contrast medium after BPA Wire injury Over dilation Pressure overlord (by contrast injection) Vascular injury due to procedural complication is the main cause of pulmonary injury.

32 BPA Technical Considerations Oxygen administration to maintain an oxygen saturation of 98% to 100% Anticoagulants are continued during the BPA procedure to maintain a prothrombin time international ratio between 2.0 and 3.0 Right femoral vein (jugular) with 8F or 9F sheath and a 6-7 F long introducer sheath (70-90 cm) (Jugular vein needs 2 operators) Appropriate guiding catheter, inch or inch guidewire is used to cross the lesion A smaller balloon relative to the actual vessel size is selected for the initial BPA session to reduce the risk of pulmonary vessel injury and restore minimal blood flow to the occluded or stenotic pulmonary vessels In a subsequent session, a balloon catheter of % the size of the reference vessel diameter indicated on the angiogram is selected to optimize the dilatation of the lesion (and if previously a mean PA < 35 mmhg has been achieved, or else dilation of other untreated lesions)

33 BPA Technical Considerations There is no limitation regarding the number of lobes targeted in one session. The maximum time of radiographic fluoroscopy in a single session should be limited to 60 min. As a consequence, lesions from 4 10 sites could generally be treated in a single session. To enhance the therapeutic effect of BPA, it is important to make the area of reperfusion large, which requires repeated treatment with four sessions per patient depending on the treatment goal

34 The management options for chronic thromboembolic pulmonary hypertension (CTEPH) target different pathogenic manifestations in different parts of the pulmonary vascular bed. Michael Madani et al. Eur Respir Rev 2017;26:170105

35 First Results 1 st case/session on Dec/2016, last session 01/ pts (females 7), mean age 53±13 (34-70) syst PAP (mmhg) mean PAP (mmhg) Baseline After BPA Change (%) p-value 83.3±18 63± ±11 39± pts after PEA PVR (WU) 10± ± sessions (1-7/pt), 138 dilated vessels (15±12/pt, 3-10/session) CI (l/min/m 2 ) 2.4± ± There is no patient who completed the BPA treatment yet Sao (%) 88±6.4 92± Spa (%) 62.8± ±

36 Results (WHO class, mpap, PVR) Pts Age Sessi ons N o Vess prebpa WHO WHO after BPA prebpa mpap postbpa mpap prebpa PVR postbpa PVR IV II 37 29(-22%) (-44%) IV II-III 68 52(-24%) (-43%) III II 49 40(-18%) 8 6.2(-23%) II II 58 32(-45%) 8,9 2.9(-67%) III II 47 33(-30%) (-62%) II I III III II 59 49(-17%) 14.8

37 Conclusions Balloon pulmonary angioplasty is an effective method for treating patients with CTEPH, who could not benefit from first-line surgical therapy. A very demanding technique in complex anatomy where biplane is mandatory It is not free from potentially life-threatening complications Further refinements of the strategy to reduce complications, improvements in the simplicity of the treatment, and evaluation of the long-term follow-up results are needed before BPA can be recommended as an established treatment for CTEPH.